Efectividad de la fisioterapia multimodal acuática mediante ejercicio terapéutico, autodrenaje manual y medidas de autocuidado en el linfedema de miembro superior en mujeres supervivientes de cáncer de mama. Ensayo clínico aleatorizado / Effectiveness of aquatic multimodal physiotherapy through therapeutic exercise, manual self-drainage and self-care measures in upper limb lymphedema in female breast cancer survivors. Randomized clinical trial

Introducción El linfedema secundario al cáncer de mama es una patología crónica. La fisioterapia descongestiva compleja (FDC) es el tratamiento conservador de elección, consta de una fase intensiva para disminuir el volumen de la extremidad, y una fase de mantenimiento para fomentar el autocontrol de la patología. El objetivo es evaluar si la fisioterapia multimodal acuática (FMA) compuesta por ejercicio terapéutico, auto drenaje manual y medidas de autocuidado de miembro superior mantiene o reduce el volumen del linfedema en fase de mantenimiento y si esta es más efectiva que la fisioterapia multimodal de miembro superior en sala. Metodología Se ha realizado un ensayo clínico aleatorizado comparando dos grupos, experimental n:43 que realizó una pauta de ejercicios en el medio acuático y control n:47 que realizó la misma pauta de ejercicios en sala. Ambos grupos efectuaron 20 sesiones de 45 min, dos o tres días por semana. Se evaluaron como variables principales los cambios en el volumen del linfedema, mediante circometría y la calidad de vida de las participantes, mediante la escala FACT-B + 4. Resultados No se encontraron diferencias estadísticamente significativas entre las intervenciones realizadas, ambas mejoran el volumen a las 20 sesiones (p = 0,7855), pero si entre la frecuencia del tratamiento y el tiempo postintervención (p<0,01). Se encontraron mejoras en las variables de calidad de vida; «estado físico general del paciente», «ambiente familiar y social», «estado emocional», «capacidad de funcionamiento personal» y «preocupaciones de las pacientes» (p < 0,01). Conclusión La FMA de miembro superior parece mejorar la calidad de vida de las mujeres supervivientes con linfedema de miembro superior en fase de mantenimiento. La FMA no muestra un beneficio añadido a la fisioterapia multimodal en sala (AU)

Introduction Lymphedema secondary to breast cancer is a chronic pathology. Complex decongestive physiotherapy is the conservative treatment of choice, it consists of an intensive phase to minimize the volume of the limb, and a maintenance phase to promote self-control of the pathology. The objective is to evaluate if aquatic multimodal physiotherapy (AMP) composed of therapeutic exercise, manual self-drainage and upper limb self-care measures maintains or reduces the volume of lymphedema in the maintenance phase and if it is more effective than upper limb multimodal physiotherapy in-room. Methodology A randomized clinical trial has been carried out comparing two groups, experimental N:43 that performed a pattern of exercises in an aquatic environment and control N:47 that performed the same pattern of exercises in-room. Both groups carried out 20 sessions of 45min, 2 or 3 days per week. The main variables were the changes in the volume of the lymphedema, by means of circometry, and the quality of life of the participants, by means of the FACT-B + 4 scale. Results No statistically significant differences were found between the interventions carried out, both improve the volume at 20 sessions (p = 0.7855), the interaction between the frequency of treatment and the time after intervention was (p-value: < 0.01). Improvements were found in quality of life variables; «general physical state of the patient», «family and social environment», «emotional state», «personal functioning capacity» and «patient concerns» (p-value: < 0.01). Conclusion Upper limb AMP seems to improve the quality of life of surviving women with upper limb lymphedema in the maintenance phase. AMP does not show an added benefit to room multimodal physiotherapy (AU)

Fisioterapia precoz en transferencia del trapecio inferior para lesiones masivas e irreparables del manguito rotador. A propósito de un caso clínico / Early physiotherapy in lower trapezius transfer for massive and irreparable rotator cuff injuries. A case report

Las lesiones masivas e irreparables del maguito rotador son frecuentes entre la población mayor de 60 años. La transferencia del trapecio inferior con aloinjerto de tendón de Aquiles ha demostrado buenos resultados para restaurar la función del hombro. Para este tipo de cirugía, se recomienda inmovilización absoluta en abducción de hombro a 90° y rotación externa máxima entre 6-8 semanas. Mujer de 57 años intervenida quirúrgicamente con transferencia de trapecio inferior para reparar el manguito rotador por rotura masiva e irreparable. Inició fisioterapia acuática a los 15 días de la intervención, acompañada de tratamiento de fisioterapia convencional a los 25 días, con un seguimiento hasta los 12 meses. Se obtuvieron buenos resultados funcionales del hombro intervenido, que se mantuvieron en el seguimiento postoperatorio realizado. En este caso la fisioterapia precoz no supuso ningún riesgo de fallo de sutura, aflojamiento o destensado del injerto.(AU)

Massive and irreparable lesions of the rotator cuff are frequent between people over 60 years old. Recently, inferior trapezium transference with Achilles tendon allograft has demonstrated very good results to restore shoulder's function. For this kind of surgery, it is recommended an absolute immobilization in shoulder abduction at 90° and maximal external rotation between 6-8 weeks. A 57-year-old woman underwent surgery with a lower trapezius transfer to repair the rotator cuff due to a massive and irreparable tear. She started aquatic physiotherapy 15 days after surgery and conventional physiotherapy treatment at 25 days, with a follow-up of 12 months. Good functional results of the operated shoulder were obtained, which were maintained in the postoperative follow-up. In this case early physiotherapy did not result in any risk of suture dehiscence, loosen or distressing of the allograft.(AU)

[Early physiotherapy in lower trapezius transfer for massive and irreparable rotator cuff injuries. A case report]. / Fisioterapia precoz en transferencia del trapecio inferior para lesiones masivas e irreparables del manguito rotador. A propósito de un caso clínico.

Massive and irreparable lesions of the rotator cuff are frequent between people over 60 years old. Recently, inferior trapezium transference with Achilles tendon allograft has demonstrated very good results to restore shoulder's function. For this kind of surgery, it is recommended an absolute immobilization in shoulder abduction at 90° and maximal external rotation between 6-8 weeks. A 57-year-old woman underwent surgery with a lower trapezius transfer to repair the rotator cuff due to a massive and irreparable tear. She started aquatic physiotherapy 15 days after surgery and conventional physiotherapy treatment at 25 days, with a follow-up of 12 months. Good functional results of the operated shoulder were obtained, which were maintained in the postoperative follow-up. In this case early physiotherapy did not result in any risk of suture dehiscence, loosen or distressing of the allograft.

Improving heat and moisture exchanger therapy with a hydrogel base adhesive in laryngectomised patients: an open, randomised, crossover trial.

OBJECTIVE: This study aimed to assess individual preference, symptoms and compliance between habitual use of Provox XtraFlow and the combination of Provox XtraFlow during the day and Provox Luna during the night for heat and moisture exchanger therapy in laryngectomised patients. METHOD: This was an open, randomised, crossover trial for 25 days. After this first study period and a 5-day wash-out period, treatments were switched for another 25 days. RESULTS: A total of 28 patients were enrolled. Differences were found (p = 0.009) in the incidence of dermatological problems with XtraFlow (46.4 per cent) versus Provox Luna (14.3 per cent), as well as in the need to abandon the use of adhesives (46.4 per cent vs 10.7 per cent; p = 0.003). A total of 60.7 per cent of the patients preferred the Provox Luna system as their preference for heat and moisture exchanger therapy. CONCLUSION: The Provox Luna system is a viable additive to heat and moisture exchanger therapy, especially in the setting of compliance concerns and in patients who desire dermatological relief overnight.

Risk factors for lymphedema after breast surgery: A prospective cohort study in the era of sentinel lymph node biopsy.

INTRODUCTION: The Objective was to investigate the incidence of lymphedema after breast cancer treatment and to analyze the risk factors involved in a tertiary level hospital. METHODS: Prospective longitudinal observational study over 3 years post-breast surgery. 232 patients undergoing surgery for breast cancer at our institution between September 2013 and February 2018. Sentinel lymph node biopsy (SLNB) or axillary lymphadenectomy (ALND) were mandatory in this cohort. In total, 201 patients met the inclusion criteria and had a median follow-up of 31 months (range, 1-54 months). Lymphedema was diagnosed by circumferential measurements and truncated cone calculations. Patients and tumor characteristics, shoulder range of motion limitation and local and systemic therapies were analyzed as possible risk factors for lymphedema. RESULTS: Most cases of lymphedema appeared in the first 2 years. 13.9% of patients developed lymphedema: 31% after ALND and 4.6% after SLNB (p < 0.01), and 46.7% after mastectomy and 11.3% after breast-conserving surgery (p < 0.01). The lymphedema rate increased when axillary radiotherapy (RT) was added to radical surgery: 4.3% for SLNB alone, 6.7% for SLNB + RT, 17.6% for ALND alone, and 35.2% for ALND + RT (p < 0.01). In the multivariate analysis, the only risk factors associated with the development of lymphedema were ALND and mastectomy, which had hazard ratios (95% confidence intervals) of 7.28 (2.92-18.16) and 3.9 (1.60-9.49) respectively. CONCLUSIONS: The main risk factors for lymphedema were the more radical surgeries (ALND and mastectomy). The risk associated with these procedures appeared to be worsened by the addition of axillary radiotherapy. A follow-up protocol in patients with ALND lasting at least two years, in which special attention is paid to these risk factors, is necessary to guarantee a comprehensive control of lymphedema that provides early detection and treatment.

Linfedema facial y labial secundario a tratamiento oncológico. A propósito de un caso clínico / Facial and labial lymphedema after oncological treatment. A propos of clinical case

El linfedema facial secundario a un tratamiento oncológico es una entidad rara e incapacitante, que ocasiona alteraciones funcionales y estéticas. Presentamos el caso de una paciente de 61 años, que a raíz de una neoplasia de lengua en 2015 y tras varios tratamientos, incluyendo diversas intervenciones quirúrgicas, linfadenectomía ganglionar cervical bilateral y radioterapia adyuvante, desarrolló linfedema facial y labial. Fue remitida al servicio de rehabilitación por aumento de volumen facial y labial, sialorrea, xerostomía, dificultad para deglutir, leve disatria y protrusión labial. Debido a la repercusión funcional y el defecto estético que esto causaba a la paciente, se realizó un plan de tratamiento rehabilitador que consistió en drenaje linfático manual, colocación de ortesis facial nocturna de silicona y taping linfático. La paciente mejoró tanto subjetiva como objetivamente en términos de dureza y volumen facial, aunque observamos leve mejoría del linfedema labial (AU)

Facial lymphedema secondary to treatment by a neoplastic process is a rare and disabling pathology, causing functional and aesthetic alterations. A case report of facial and labial lymphedema describing the functional repercussion and aesthetic defect. We present a 61-years-old female patient suffered a tongue neoplasia and bilateral cervical lymphadenectomy in 2015. After several treatments, including diverse surgical interventions and adjuvant radiotherapy, developed facial and labial lymphedema. The patient was sent to our Rehabilitation Department complaining about swelling of the face and lips, dysphagia, sialorrhea, xerostomia, dysarthria and decubitus in lower lip by labia protusion. Due to the functional repercussion that it caused in the patient, rehabilitating physical treatment was planned with manual lymph drainage, facial silicone orthosis and lymphatic taping. The patient improved both subjectively as well as objectively in terms of hardness, volume and slight improvement of lip lymphedema (AU)

[Facial and labial lymphedema after oncological treatment. A propos of clinical case]. / Linfedema facial y labial secundario a tratamiento oncológico. A propósito de un caso clínico.

Facial lymphedema secondary to treatment by a neoplastic process is a rare and disabling pathology, causing functional and aesthetic alterations. A case report of facial and labial lymphedema describing the functional repercussion and aesthetic defect. We present a 61-years-old female patient suffered a tongue neoplasia and bilateral cervical lymphadenectomy in 2015. After several treatments, including diverse surgical interventions and adjuvant radiotherapy, developed facial and labial lymphedema. The patient was sent to our Rehabilitation Department complaining about swelling of the face and lips, dysphagia, sialorrhea, xerostomia, dysarthria and decubitus in lower lip by labia protusion. Due to the functional repercussion that it caused in the patient, rehabilitating physical treatment was planned with manual lymph drainage, facial silicone orthosis and lymphatic taping. The patient improved both subjectively as well as objectively in terms of hardness, volume and slight improvement of lip lymphedema.

El reto de una unidad de cuidados intensivos en un recinto ferial / The challenge of an intensive care unit in a fairground

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Case report of segmental odontomaxillary dysplasia with cutaneous manifestations.

BACKGROUND: Segmental odontomaxillary dysplasia is an uncommon nonhereditary growth disorder that affects the maxilla, gums and ipsilateral dentition. The disorder is diagnosed mainly based on dental (over-retention of primary teeth, dental agenesis and diastemas) and bone findings (bone sclerosis, irregular trabeculation of immature bone and reduced maxillary sinus). This paper provides a case report. CASE REPORT: A 5-year-old child with skin manifestations including hypertrichosis, facial erythema and pigmented nevus was diagnosed with type II segmental odontomaxillary dysplasia based on clinical, radiographic and histopathological analysis. CONCLUSION: The skin findings can help with the suspicion of segmental odontomaxillary dysplasia, although the definitive diagnosis is typically established by a paediatric dentist based on clinical and radiological findings.

Asistencia en cuidados críticos de una unidad de Sanidad Militar dentro del hospital de campaña en la Institución Ferial de Madrid durante la crisis SARS-CoV-2 / Assistance of a Military Health Unit deployed in «Institucion Ferial de Madrid» field hospital during SARS-CoV-2 crisis

INTRODUCCIÓN: Durante la pandemia por coronavirus SARS-CoV-2 que afectó a España durante la primavera del año 2020, muchos de los hospitales se colapsaron por la afluencia de estos pacientes. Por este motivo se desplegó en la Institución Ferial de Madrid (IFEMA) un hospital de campaña. La única unidad de críticos de este hospital fue militar. La unidad responsable de su montaje, mantenimiento y repliegue fue la Unidad Médica Aérea de Apoyo al Despliegue (UMAAD) de Madrid perteneciente al Ejército del Aire. OBJETIVO: Describir la asistencia médica prestada en la unidad de críticos de IFEMA. MATERIAL Y MÉTODOS: Estudio descriptivo prospectivo realizado del 19 de marzo al 30 de abril de 2020. Se consiguió la autorización militar de la Dirección de Sanidad del Ejército del Aire para la realización del estudio. RESULTADOS: Durante el periodo de estudio 25 pacientes ingresaron en la unidad durante la Operación «Balmis». La mayoría fueron varones y de raza hispana, el motivo de ingreso fue por neumonía por SARS-CoV-2. Se aisló la vía aérea en el 88% de los pacientes. Las principales complicaciones fueron trombosis, hemorragia e hipertensión, falleciendo tres pacientes durante la realización del estudio. CONCLUSIÓN: La experiencia adquirida en este despliegue, demuestra, una vez más, la importancia de los apoyos que la Sanidad Militar puede prestar a la Sanidad Civil en el que el componente sanitario de la gestión de crisis en territorio nacional

INTRODUCTION: During the coronavirus SARS-CoV-2 pandemic that affected Spain in spring of 2020, many of hospitals were collapsed by these patients. For this reason, a field hospital was deployed at the «Institución Ferial de Madrid» (IFEMA). The only critical unit of this field hospital was military. The unit responsible for its deployment, maintenance and withdrawal was UMAAD (Madrid Deployment Support Air Medical Unit belonging to the Air Force). OBJECTIVE: To describe medical assistance provided in the IFEMA critical unit. MATERIAL AND METHODS: Prospective descriptive study carried out from March 19 to April 30, 2020. The pertinent military authorization (Air Force Health Service Director) was obtained to carry out the study. RESULTS: During the study time, 25 critically ill patients were admitted. Most of them were male and Hispanic race. SARS-CoV-2 pneumonia was the reason for hospital admission. Airway was performed in 88% of patients. Principal complications were thrombosis, hemorrhage and hypertension. Three patients died during this research paper. CONCLUSION: The experience acquired in this deployment demonstrates, once again, the importance of the support that Military Health can provide to Civil Health in the component of crisis management in national territory

Blood transfusion in children at a university hospital in a middle-income country: The need to reinforce adherence to current guidelines.

OBJECTIVES: Blood component transfusion is a common procedure used during hospital admissions; however, it is not risk-free. The evaluation of correct use of blood products (BP) is of vast importance considering the risks and costs implied in their use. Our principal objective was to evaluate the adherence to national guidelines for blood transfusion in pediatric patients at a third level university hospital. MATERIAL AND METHODS: A prospective and retrospective descriptive analytical study was conducted to report the incidence of incorrect use of BP in pediatric patients (1 month to 16 years of age). In a timeline period of 4 years, 579 medical records were randomly selected from a total of 6575 transfusions realized to create a statistically significant sample. The variables studied were volume, infusion time, and transfusion criteria. Indications were evaluated in patient's medical records according to national guidelines. RESULTS: Of the transfusions analyzed, 54% were classified as incorrect mainly due to lack of transfusion criteria fulfillment. Blood transfusion indications in pediatric patients adhered poorly to national guidelines. CONCLUSION: The implementation of effective programs for education and information on the use of BP are needed to increase compliance with current guidelines.

Transient callosal projections of L4 neurons are eliminated for the acquisition of local connectivity.

Interhemispheric axons of the corpus callosum (CC) facilitate the higher order functions of the cerebral cortex. According to current views, callosal and non-callosal fates are determined early after a neuron's birth, and certain populations, such as cortical layer (L) 4 excitatory neurons of the primary somatosensory (S1) barrel, project only ipsilaterally. Using a novel axonal-retrotracing strategy and GFP-targeted visualization of Rorb+ neurons, we instead demonstrate that L4 neurons develop transient interhemispheric axons. Locally restricted L4 connectivity emerges when exuberant contralateral axons are refined in an area- and layer-specific manner during postnatal development. Surgical and genetic interventions of sensory circuits demonstrate that refinement rates depend on distinct inputs from sensory-specific thalamic nuclei. Reductions in input-dependent refinement result in mature functional interhemispheric hyperconnectivity, demonstrating the plasticity and bona fide callosal potential of L4 neurons. Thus, L4 neurons discard alternative interhemispheric circuits as instructed by thalamic input. This may ensure optimal wiring.

Treatment of severe recurrent hepatitis C after liver transplantation in HIV infected patients using sofosbuvir-based therapy.

BACKGROUND: For liver transplant recipients with hepatitis C virus (HCV) and human immunodeficiency virus (HIV) co-infection, recurrence after LT is associated with a higher risk of graft loss than for HCV mono-infected patients. Prior HCV treatment options were limited by side effects and drug-drug interactions. AIM: To evaluate treatment outcomes with sofosbuvir (SOF)-based therapy among HIV/HCV coinfected liver transplant recipients. METHODS: Access to SOF and ribavirin (RBV) prior to regulatory approval was attained via an international compassionate access program for transplant recipients with a life expectancy of 1 year or less in the absence of HCV treatment. This report focuses on the short and longer term outcomes in HCV-HIV co-infected liver transplant recipients. RESULTS: Twenty patients were treated, nine with early severe recurrence and 11 with cirrhosis. Eleven patients received SOF and RBV, one SOF, RBV and Peg-interferon, three SOF, RBV and simeprevir and five SOF, RBV and daclatasvir. Of the 18 patients who completed treatment, 16 (89%) achieved sustained virological response 12 weeks after the end of treatment (SVR12). Liver function tests (including bilirubin and albumin) improved significantly over time. Nineteen serious adverse events occurred in eight (40%) patients, none of them related to SOF. Two patients died during treatment and another, 1 year after the end of therapy, due to progressive end-stage liver disease. Importantly, HIV suppression was not compromised. No significant drug-drug interactions were reported. CONCLUSIONS: Sofosbuvir-based regimens are safe, well-tolerated and provide high rates of SVR in HCV-HIV co-infected patients with severe recurrence after-liver transplant.

Analysis of adult 20-year survivors after liver transplantation.

BACKGROUND: Liver transplantation (LT) is the treatment of choice for chronic and acute liver failure; however, the status of long-term survivors and allograft function is not well known. AIM: To evaluate the clinical outcome and allograft function of survivors 20 years post-LT, cause of death during the same period and risk factors of mortality. METHODS: A retrospective study was conducted from prospective, longitudinal data collected at a single center of adult LT recipients surviving 20 years. A comparative sub-analysis was made with patients who were not alive 20 years post-transplantation to identify the causes of death and risk factors of mortality. RESULTS: Between 1988 and 1994, 132 patients received 151 deceased-donors LT and 28 (21%) survived more than 20 years. Regarding liver function in this group, medians of AST, ALT and total bilirubin at 20 years post-LT were 33 IU/L (13-135 IU/L), 27 (11-152 IU/L) and 0.6 mg/dL (0.3-1.1 mg/dL). Renal dysfunction was observed in 40% of patients and median eGFR among 20-year survivors was 64 mL/min/1.73 m(2) (6-144 mL/min/1.73 m(2)). Sixty-one percent of 20-year survivors had arterial hypertension, 43% dyslipidemia, 25% de novo tumors and 21% diabetes mellitus. Infections were the main cause of death during the 1st year post-transplant (32%) and between the 1st and 5th year post-transplant (25%). After 5th year from transplant, hepatitis C recurrence (22%) became the first cause of death. Factors having an impact on long-term patient survival were HCC indication (p = 0.049), pre-transplant renal dysfunction (p = 0.043) and long warm ischemia time (p = 0.016); furthermore, post-transplant factors were diabetes mellitus (p = 0.001) and liver dysfunction (p = 0.05) at 1 year. CONCLUSION: Our results showed the effect of immunosuppression used during decades on long-term outcome in our LT patients in terms of morbidity (arterial hypertension, diabetes mellitus, dyslipidemia and renal dysfunction) and mortality (infections and hepatitis C recurrence).

El paciente con cáncer en la unidad de vigilancia intensiva. Nuevas perspectivas / Patients with cancer in the intensive monitoring unit. New perspectives

Durante los últimos años, se ha evidenciado una mejoría significativa en la supervivencia de los pacientes con cáncer en las unidades de cuidados intensivos (UCI). Tanto el avance en el tratamiento médico y quirúrgico, como una mejor selección de pacientes, han influido en la mejoría de las expectativas vitales de estos enfermos. En la UCI una resucitación adecuada y precoz, sin limitaciones iniciales a técnicas de soporte vital, ha demostrado disminuir también la mortalidad en los pacientes con cáncer. Actualmente, no debemos denegar el ingreso en UCI solo por la enfermedad neoplásica de base. Aun así, la mortalidad del paciente con cáncer en la UCI, especialmente el hematológico, sigue siendo alta y en algunos casos es necesario realizar una prueba de ingreso en UCI (test de UCI) de, al menos, 3 días para diferenciar a los pacientes que se estén beneficiando de un tratamiento intensivo. Proponemos un algoritmo de decisión al ingreso en la UCI que nos ayude en una situación, a veces, compleja (AU)

In recent years, there has been a significant improvement in the survival of patients with cancer in intensive care units (ICUs). Advances in medical and surgical treatments and better selection of patients has helped improve the life expectancy of this type of patient. An appropriate and early resuscitation in the ICU, without initial limitations on the life support techniques, has been shown to also decrease the mortality of patients with cancer. At present, we should not deny admission to the ICU based only on the underlying neoplastic disease. However, the mortality rate for patients with cancer in the ICU, especially those with hematologic disease, remains high. In some cases, an ICU admission test (ICU test) is required for at least 3 days to identify patients who can benefit from intensive treatment. We would like to propose a decision algorithm for ICU admission that will help in making decisions in an often complex situation (AU)